The nurse is caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS) whose most recent laboratory values reveal a CD4 level less than 200. Which assessment findings require immediate intervention?

Oral candidiasis and nausea

Genital ulcer and vomiting

Memory deficit and apathy

Progressive dyspnea and fever

Answer and Explanation

The Correct Answer is D

A. Oral candidiasis and nausea: Oral candidiasis (thrush) and nausea are common manifestations in patients with AIDS, particularly when the CD4 count is low. While these symptoms require intervention, they are not typically considered emergent or immediately life-threatening.

B. Genital ulcer and vomiting: Genital ulcers and vomiting can occur in patients with AIDS due to various opportunistic infections and conditions. While these symptoms may warrant intervention, they are not typically indicative of an immediate life-threatening situation.

C. Memory deficit and apathy: Memory deficits and apathy can occur in patients with AIDS, particularly as the disease progresses. While these cognitive and behavioral changes may impact the patient's quality of life and require intervention, they are not typically considered emergent or immediately life-threatening.

D. Progressive dyspnea and fever: Progressive dyspnea (difficulty breathing) and fever are concerning findings in a patient with AIDS, especially with a CD4 count less than 200. These symptoms may indicate the presence of opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP), which can rapidly progress and lead to respiratory failure and death if not promptly treated. Therefore, these assessment findings require immediate intervention to assess for and manage potential respiratory compromise and systemic infection.

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Correct Answer is B

Explanation

A. The partial thromboplastin time is 30 seconds:

The partial thromboplastin time (PTT) measures the clotting time of blood and is typically used to monitor patients on heparin therapy, not warfarin. A PTT of 30 seconds is within the normal range and does not directly relate to warfarin therapy. Therefore, it does not require immediate follow-up in the context of warfarin administration.

B. The International normalized ratio is 6.0:

The International Normalized Ratio (INR) is a standard measure used to monitor the effectiveness of warfarin therapy. For most indications, the therapeutic range for INR is typically between 2.0 and 3.0. A value of 6.0 indicates that the patient's blood is taking six times longer to clot than normal, suggesting a significantly increased risk of bleeding. Therefore, this result requires immediate follow-up by the nurse to assess the patient's condition and potentially adjust warfarin dosage to reduce the risk of bleeding.

C. Creatinine is 12:

Creatinine is a waste product generated by muscle metabolism and is filtered out of the blood by the kidneys. Elevated levels of creatinine may indicate impaired kidney function, but this result does not directly relate to warfarin therapy. While an elevated creatinine level may require follow-up for other reasons, it does not necessitate immediate action related to warfarin therapy.

D. The patient's hematocrit level is 43%:

Hematocrit is a measure of the proportion of red blood cells in the blood. A hematocrit level of 43% is within the normal range for both men and women and does not directly relate to warfarin therapy. While changes in hematocrit may occur in some patients taking warfarin, this result alone does not require immediate follow-up in the context of warfarin administration.

A. Continue to administer the metoprolol tartrate as ordered. B. Ask the patient if her pulse is within the normal range C. Hold the medication and call the provider D. Ask the patient to eat salty foods

Correct Answer is C

Explanation

A. Continue to administer the metoprolol tartrate as ordered:
Metoprolol is a beta-blocker commonly used to treat hypertension, angina, and heart failure. One of its main effects is to decrease heart rate and blood pressure. In this scenario, the patient's vital signs reveal a low heart rate (48 bpm) and relatively low blood pressure (100/50 mmHg). Given that metoprolol can further reduce heart rate and blood pressure, it would be prudent for the nurse to withhold the medication until further assessment is conducted.

B. Ask the patient if her pulse is within the normal range:
While it's essential to assess the patient's understanding of her condition, asking if her pulse is within the normal range is not sufficient. The nurse should perform a more thorough assessment and consider the clinical significance of the vital signs obtained. In this case, a heart rate of 48 bpm is lower than the typical normal range for adults (60-100 bpm), indicating bradycardia, which may be symptomatic or concerning in the context of administering a beta-blocker like metoprolol.

C. Hold the medication and call the provider:
Given the patient's low heart rate (bradycardia) and relatively low blood pressure, holding the metoprolol tartrate and contacting the healthcare provider is the most appropriate action. Bradycardia and hypotension can be signs of excessive beta-blockade, especially with medications like metoprolol, which can further lower heart rate and blood pressure. The nurse should notify the provider promptly to discuss the patient's condition and determine the appropriate course of action.

D. Ask the patient to eat salty foods:
Encouraging the patient to eat salty foods would not address the underlying issue of bradycardia and hypotension. While increasing salt intake may help raise blood pressure in some cases, it is not a standard intervention for managing symptomatic bradycardia or low blood pressure caused by medication effects.

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The nurse is caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS) whose most recent laboratory values reveal a CD4 level less than 200. Which assessment findings require immediate intervention?

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Correct Answer is B

Explanation

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Correct Answer is C

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